Monthly Archives: August 2010

The alcohol-breast cancer connection was in the news this week. According to a report in the August 23 issue of the Journal of the National Cancer Institute, regular alcohol consumption increases the risk of hormone-receptor positive breast cancer, but apparently does not increase the risk of invasive ductal carcinoma in situ (DCIS). The authors said it was the first major study to look at the potential connection by cancer subtype. The women they looked at ranged from complete teetotalers to women who drink from 1 to more than 14 drinks a week.

When I read about this, I wasn’t sure whether to pat myself on the back or spank myself, since I had estrogen-receptor positive DCIS and I fall into the drinking category. I fall somewhere between role model and dire warning. I got carried away from time to time when I was younger, just as I used to worship the sun. The nice thing about getting older is you just naturally slow down. Hangovers and sweating in the sun have both lost their appeal for me. I’m nowhere near the 14 drink per week tally.

I will tell you that as soon as I was diagnosed I wondered if my youthful misbehavior brought anything to the party, but I decided pretty quickly not to beat myself up. I know women who have never touched a drop of alcohol in their lives and got breast cancer. I know other women who should have had full chest and liver replacements by now and (so far) are cancer-free. I really believe there’s some genetic luck of the draw at play.

I also believe the alcohol question is similar to choosing a course of treatment. We have to weigh the risks and benefits and make the choice that’s best for us as individuals. I like wine with dinner and I never met a glass of champagne I didn’t like. My choice is to continue enjoying that in moderation (although as the saying goes “Moderation in all things, including moderation.”)

The morning after my mastectomy, I asked my surgeon if it would be okay to have a glass of champagne on our 33rd wedding anniversary the following day. He’s one of the more relaxed human beings on the planet, and he said, “Sure, have two if you want.” My nurses were scandalized by that. (For the record, I did have two glasses. Hey, doctor’s orders!)

I guess what I”m trying to say is that I’m trying to strike a balance between my vices and enjoying life. I exercise more, and more often, than I ever have. I don’t text (or drink) and drive. I don’t eat or drink to excess but I think good food and drink are two of life’s great joys and I plan to enjoy them both for as long as I live. Now if you’ll excuse me, I’m going to go have a mimosa.

Whether you’re newly diagnosed with DCIS or a more advanced form of breast cancer, you’ll notice it has a big time impact. One of the things that surprised me was just how much breast cancer chews up your schedule. I had something like 38 appointments in 20 weeks, and this did not include radiation, which was not in my treatment plan.

In case you’re wondering what all those appointments were for, I had two attempts at breast-conserving surgery, followed by a mastectomy with immediate first-stage reconstruction (This was followed a couple of months later by second-stage reconstruction and augmentation/lift of the other breast, followed by nipple reconstruction. They are not included in my appointment tally.)

Each surgery required consultations and follow-ups with my surgeon and/or plastic surgeon, and my family doctor and oncologist both wanted to track my progress. I believe all these visits were necessary; I just want to give you a sense of how much time the process can take.

The bigger thing you should be aware of is the pressure you may feel to do something right now once you’ve been diagnosed. Do not give in to that pressure. DCIS is very early stage, technically stage 0, so you are not putting yourself at risk by giving yourself time to think.

You’ll need it, because like so many things you don’t realize until you get there, your choice in breast cancer treatment is not written in stone. I had to decide between mastectomy and radiation. I also had to decide whether I wanted immediate reconstruction, and whether I wanted reconstruction on the other breast. The reconstructive choices were no brainers. Deciding between mastectomy and radiation, not so much.

While I was trying to decide, my mind was spinning so much I felt like a hamster on a wheel. I had to give myself permission to take the day off from thinking about it a couple of times, and it wasn’t easy. Distractions like movies gave me something to focus on aside from the contents of my head.

I should add that my time pressure was self-induced. My doctors were very good about giving me time, although my oncologist said I should take some time but not too much. I think he wanted to make sure I didn’t stall myself into total paralysis. I realize this may not be the case for everyone. If anyone, whether a doctor or family member, tries to pressure you into making a decision before you’re ready, don’t do it.

It’s your body and ultimately, your decision. Give yourself time to make the one that’s best for you.

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Note: I wrote this guest post for KevinMD.com and it generated a fair number of comments.

I’ve been hearing and reading a lot lately about how the doctor-patient relationship is under siege. There are many reasons for this, ranging from care decisions increasingly being made by insurers to the shortage of primary care physicians, to patient empowerment. I didn’t quite understand how patient empowerment could be a threat, until I started thinking about the recent perceptual shift from patients to health-care consumers.

I agree with the consumer definition, but only up to a point. I live in a large enough population center that I can shop around until I find a doctor I like. But for me, that’s where the consumer metaphor ends. We may consume health care services, but it’s nothing like purchasing a car or a sofa.

Yet people increasingly seem to think it is. They think doctors should be the equivalent of a 24-hour shopping website, at our beck and call whenever the mood strikes because as we all know, instant gratification takes too long. They should be available by e-mail and Facebook and texting and if they are not, they are not providing good customer service, as one blog commenter recently said.

Well, I’m sorry but that point of view is what my dad would call “horse manure.” I had four remarkable doctors—my family doctor, general surgeon, oncologist and plastic surgeon—guide me through five surgeries for early stage breast cancer. Not once did I feel like I was receiving poor “customer service” because I couldn’t reach them by e-mail.

Now, I do agree that we shouldn’t be so blinded by the white coats that we don’t ask questions when we don’t understand a medical term, or when we want to know why a doctor recommends a certain course of action. (And if a doctor sees your questions as an insult, then yes, you should make like a consumer and take your business somewhere else. The good ones welcome your questions and respect your concerns.) But being assertive is an order of magnitude removed from demanding a drug or treatment because we read something on the internet, or thinking it’s okay to take a phone call in the middle of a consultation. The very clear message is that we don’t value their time or considerable skills.

Speaking of skills, I’d really like to know where you get off treating someone who spends at least 11 years in training as the hired help. This arrogant viewpoint can only erode trust, the linchpin of the doctor-patient relationship. My family doctor told me that the word “doctor “comes from the Greek for “teacher,” and that teaching is a large part of what they do. I can vouch for that, as he was my breast cancer sherpa. I never could have gotten through this experience without him. Because I trusted him, I trusted the specialists he referred me to. And because I trusted them, I trusted their surgical and staff teams. See how that works? I’m happy to report that my trust was well-placed.

I’m also happy to consider myself their patient. Maybe the word “patient” has become equated with “subservient” in some circles, but I’m not buying it. I see no power struggles here. To me, being a patient means I’m in the care of people who have committed themselves to healing and helping others. What could possibly be wrong with that? Nothing, unless I see my almighty consumer self as the center of the universe, and doctors as just another set of sales clerks.

So please, unless you see me at the mall shopping for shoes, don’t call me a consumer.

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I once worked with a psychiatrist who called listening the most underrated skill, and his words are truer now than ever. Listening is hard work; too often, we just wait for our turn to talk. And that’s if we’re being polite. We don’t talk to each other; we talk at each other or sometimes over each other in the loudest voice possible.

This trend is both sad and wrong, but there is hope, as evidenced by the thoughtful posts I received on all facets of communication. In the wonderful post The Hidden Pearls of Medicine: Stories From Our Patients, Medical Resident recalls a first patient encounter. MR calls hearing patient stories a privilege and “has been left with a sense of wonder” after these encounters. On behalf of patients everywhere, thank you.

Fads in communication come and go, and Will Meek, a psychologist in Vancouver, wrote about discredited psychological treatments (Neuro-linguistic Programming, anyone?) He also offers sound advice about finding treatment that stands the test of time.

Erin is a pre-med student who has cerebral palsy. Like other chronic illnesses, it comes with assumptions and stereotypes, which she dismantles in “Cerebral Palsy: What It Isn’t.” I predict that her experience will make her a compassionate doctor.

Speaking of compassion, one of the toughest parts of being a doctor must be sharing bad news. Anne Marie, a family doctor and clinical lecturer at Cardiff University in Wales, shows us how medical students learn this difficult art in Teaching Communication Skills. Bongi, a general surgeon in South Africa who blogs at Other Things Amanzi, shares a real-life story in Salt Water Wells Up. And Marie, who blogs at Nourish Ourselves, describes being on the receiving end of such news in Breaking News, Breaking Faith.

But not all communication is sad. Dr. Michael Kirsch at MDWhistleblower decodes The VIP Patient: Doctor, What If I Were Your Mom? His fill in the blank examples are priceless. Sharp Incisions, the blog and nom de plume of a medical student, shows how a stethoscope can become a successful if unconventional communication tool. And Elizabeth, a medical resident in Texas who blogs at OB Cookie, explains how her conversational and party Spanish didn’t quite cut it in the gynecology arena. In addition to being very funny, I love how her affection for her patients shines through.

Like it or not, technology is affecting the way we communicate. Jill of All Trades, MD has a funny but pointed take on cell phones in Mission Impossible. (You’ll want your sound turned up to get the full effect.)

And the Happy Hospitalist’s Patient Initiated Rapid Response Teams has a bit of a Brave New World feel, as it takes patient empowerment to its not-so-logical conclusion (and it involves cell phones! I’m sensing a theme here.)

Empowerment was not in the medical research vernacular in 1951, when Henrietta Lacks died of metastatic cervical cancer. In Henrietta’s Cells Speak, Dr. Elaine Schattner recounts how Ms. Lacks’ poor, uneducated family had no idea her cancer cells were bought, sold and used at research institutions worldwide.

It’s not always about doctors and patients. Nurses are an important part of the equation, and Jacqueline, who blogs at Laika’s MedLibLog, offers 10 Random Tips for Nurses.

Communicating is connecting, and I want to close with what I consider the ultimate example of human connection, Flowers for the Lovely Wounded at the Examining Room of Dr. Charles. In the tradition of William Carlos Williams, Dr. Charles is both doctor and poet. (Check out his poetry contest.) I wonder if that’s what made him so good at hearing what his patient didn’t say. Dr. Charles, I know she remembered those flowers and your kindness until the day she died.

Next week’s Grand Rounds will be hosted by Dr. Ed Pullen at DrPullen.com. His theme is In the Office, which can be wherever you give or receive medical care.

Thanks so much to all who submitted. This was truly an honor. Now if you’ll excuse me, I have to go get my “I Hosted Grand Rounds” badge.

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Next Tuesday, August 10, is my turn to host Grand Rounds, a weekly roundup of the best in healthcare blogging, and you can scroll down to last week’s post to see what my theme is and how to contact me. But I have an update you may be interested in: I’m giving everyone a deadline extension. I originally asked for entries by noon Eastern time on Saturday: I’m extending that to 3 p.m. Eastern time on Sunday. (Early entries are still welcome!)

Why, you ask? Oh, you didn’t ask? Well, bear with me. Because my husband Bruce and I are busy with a Komen Race for the Cure event. Our dear friend Pam is squaring off against the Stage 4 Beast and we’re walking for her. When I signed up for Grand Rounds I didn’t remember they were the same weekend. I was trying to give myself more time to review but since I can’t do that, I figured if you’re like me and try to cram blogging into nights and weekends, you might appreciate the extra day.

The cancer news you can use is in regard to two things: First, Christina Applegate announced her new breast cancer foundation, Right Action for Women. Its purpose is to help women who can’t afford recommended preventive care such as MRIs. I can personally vouch for how pricey they are; mine cost around $4,000 two years ago. I was lucky because my health insurance covered it. The foundation is still under development but they do have a website.

I discovered the second thing in an ad in the Wall Street Journal. This may not be news to you but it was to me; it’s the Corporate Angel Network, a national charity that arranges free travel to treatment for cancer patients using empty seats on corporate and fractional ownership flights. That’s all I know; I haven’t done any research. But if you know someone who might benefit, please pass it on.

That’s all I’ve got for now; hope to see you at Grand Rounds next Tuesday. Thanks to Dr. Mike Cadogan over at Life in The Fast Lane, who hosted this week with a killer post theme and included a heads-up for my turn.